Factors influencing cosmetic results after breast conserving management (Turkish experience)

Prevalence, Clinical Significance and Risk Factors for Developing Scar Pain and Sensibility Disorders in Breast Cancer Patients after Breast-Conserving Therapy and Mastectomy

Introduction

The aim of this study was to gather information on the prevalence and risk factors for scar pain and sensibility disorders after breast cancer surgery, as only limited information of these complaints are available.

Material and Methods

A clinical cohort study using a non-validated questionnaire was conducted among women who presented to routine follow-up at the Breast Cancer Center Rostock, Germany. The subjects were informed that the subjective perception and sensation were in the foreground and that the questionnaire had to be filled out independently according to the current feeling.

Results

Overall 175 patients could be evaluated. The prevalence of scar pain was 30.8% after breast conserving therapy (BCT) and 34.5% after mastectomy. Following BCT 87.5%, respectively 81.8% of women after mastectomy were very satisfied or satisfied with the scarring. Sensory disorders were increased in the mastectomy group (p = 0.001). Scar pain after previous surgery was a risk factor to develop sensory disorders after BCT (p = 0.008) and mastectomy (p = 0.029). For patients receiving mastectomy, sensory disorders after previous breast surgeries increased the risk for sensory disorders (p = 0.029). Smoking was a risk factor for sensory disorders after mastectomy (p = 0.048). Multivariate analysis could not confirm any of the risk factors.

Conclusion

This study demonstrated a high satisfaction with scarring after breast surgery and a low level of scar pain. A lack of postoperative information, as well as a low level of actually performed scar care after surgery were observed. Increased focus should be on improved information on postoperative scare care.

Lateral Thoracodorsal Flap Revisited: An Underappreciated Workhorse

BACKGROUND

Although, the lateral thoracodorsal flap is a well described technique, its utility seems to be lost in the ever evolving world of oncoplastic breast surgery. This study reviews the technique, its indications and limitations and the advantage of this technique.

METHODS

Between January 2016 and January 2018, data from 7 consecutive patients who underwent partial breast mastectomy with lateral thoracodorsal flap were enrolled. A wedge shaped flap was designed using the pinch test using the index finger and the thumb in small defects, while larger defects required a convex shaped incision with curved superior and inferior borders. Incision was made along the marked margins of the proposed flap and deepened to the underlying serratus anterior and latissimus dorsii muscle. The flap was transposed in the defect and the symmetry of mound between the two breasts confirmed in sitting and supine position.

RESULTS

All patients were satisfied by cosmetic outcomes on visual analog scale (VAS). Cosmetic results based on Harvard scale showed good to excellent scores. Evaluation by Breast Cancer Conservation Treatment (BCCT) core software illustrated good to excellent cosmetic outcomes. There was no delayed wound healing, marginal skin ornecrosis and no evidence of any fat necrosis in the follow up period.

CONCLUSION

The versatility of latissimus dorsii flap, good aesthetic and functional results and its simple execution made it an important option in the armamentarium of the oncoplastic breast surgeon. Also, morbidity of the donor site was minimized without sacrificing muscles or nerves.

A Prospective Study of Cosmetic Outcomes for Patients Treated with Breast Conservation and Radiation Therapy using Shorter Fractionation Schedules at Auckland Hospital, New Zealand

AIMS

Breast cosmesis is an important outcome for women after breast conservation. It has been shown to be correlated with better patient satisfaction, sexuality and self-esteem. This study reports the subjective and objective breast cosmesis outcomes for women treated at Auckland Hospital Radiation Oncology Department using hypofractionated radiation therapy.

MATERIALS AND METHODS

Breast cosmesis was evaluated using a subjective questionnaire and standardised photographs before radiation, at 6 weeks, 1 year, 3 years and 5 years after radiation. Objective evaluation of the photographs and completion of questionnaires were undertaken by clinicians at the same time points. The questionnaire evaluated global cosmesis on a four-point scale - excellent (E), good (G), fair (F) and poor (P). Patient, tumour and treatment factors were evaluated to assess the impact on cosmesis.

RESULTS

Three hundred and fifty-eight patients completed the baseline assessments and two hundred and two patients completed the 5-year assessments. Sixty-eight per cent of patients at baseline and 70% at 5 years scored their cosmesis as E/G compared with 52% and 51%, respectively, by clinician assessment. Age >50 years, separation ≤25 cm, non-diabetic, T1 tumours, node negative, quadrant of the scar, no boost and no adjuvant endocrine therapy were correlated with E/G cosmesis. On multivariate analysis at baseline, the individual breast factors that were significantly associated with a score of E/G cosmesis were breast shape (P = 0.028) and scar appearance (P = 0.001). At 5 years, breast shape (P = 0.003), nipple shape (P = 0.019) and scar appearance (P = 0.001) were found to be significant.

CONCLUSION

This study shows that most women reported no significant change in their breast cosmesis after hypofractionated radiation treatment over 5 years and that a number of patient, tumour and treatment factors may impact on breast cosmesis.

Determinants for patient satisfaction regarding aesthetic outcome and skin sensitivity after breast-conserving surgery

Background

With the development of new surgical techniques in breast cancer, such as oncoplastic breast surgery, increased knowledge of risk factors for poor satisfaction with conventional breast-conserving surgery (BCS) is needed in order to determine which patients to offer these techniques to. The aim of this study was to investigate patient satisfaction regarding aesthetic result and skin sensitivity in relation to patient, tumour, and treatment factors, in a consecutive sample of patients undergoing conventional BCS.

Methods

Women eligible for BCS were recruited between February 1, 2008 and January 31, 2012 in a prospective setup. In all, 297 women completed a study-specific questionnaire 1 year after conventional BCS and radiotherapy. Potential risk factors for poor satisfaction were investigated using logistic regression analysis.

Results

The great majority of the women, 84%, were satisfied or very satisfied with the overall aesthetic result. The rate of satisfaction regarding symmetry between the breasts was 68% and for skin sensitivity in the operated breast it was 67%. Excision of more than 20% of the preoperative breast volume was associated with poor satisfaction regarding overall aesthetic outcome, as was axillary clearance. A high BMI (≥30 kg/m²) seemed to affect satisfaction with symmetry negatively. Factors associated with less satisfied patients regarding skin sensitivity in the operated breast were an excision of ≥20% of preoperative breast volume, a BMI of 25–30 kg/m², axillary clearance, and radiotherapy. Re-excision and postoperative infection were associated with lower rates of satisfaction regarding both overall aesthetic outcome and symmetry, as well as with skin sensitivity.

Conclusions

Several factors affect patient satisfaction after BCS. A major determinant of poor satisfaction in this study was a large excision of breast volume. If the percentage of breast volume excised is estimated to exceed 20%, other techniques, such as oncoplastic breast surgery, with or without contralateral surgery, or mastectomy with reconstruction, may be considered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-016-1053-8) contains supplementary material, which is available to authorized users.

Predictors of early poor aesthetic outcome after breast-conserving surgery in patients with breast cancer: initial results of a prospective cohort study at a single institution

BACKGROUND AND OBJECTIVES

The aim of this study was to explore features of patients reporting early poor aesthetic outcome after simple breast-conserving surgery.

METHODS

We prospectively evaluated 709 patients shortly after breast-conserving surgery. Aesthetic outcome was measured by aesthetic status scores of the Breast Cancer Treatment Outcome Scale. Clinical, surgical, and pathologic variables were assessed to identify predictors of poor aesthetic outcome.

RESULTS

Poor aesthetic outcome was reported by 46 (6.5%) patients, and 209 (29%) patients reported an intermediate aesthetic outcome. A single factor analysis of variance showed a negative impact of higher specimen weight (P < 0.001). Univariate logistic regression analysis revealed the following significant risk factors for poor aesthetic outcome: 12 o'clock positioning of tumor localization, a tumor behind the nipple areolar complex (NAC), fishmouth-shaped incision with resection of the NAC, quadrantectomy, central segmental resection, and pT stages 3 and 4. Multivariate logistic regression analysis indicated statistically independent associations between poor aesthetic outcome and tumor position in the inner half of the breast or behind the NAC, quadrantectomy, and pT stages 3 and 4.

CONCLUSION

Poor aesthetic outcome is relatively rare shortly after breast-conserving surgery, but predictable in specific situations.

["V" axillary incision for the management of tumors of upper outer quadrant and axillary tail of the breast: retrospective study and technical description]

INTRODUCTION

Tumors of the upper outer quadrant of the breast represent the most common location of breast malignant tumors. Although the choice of surgical approach should be dictated primarily by an imperative of oncological safety, esthetic and practical considerations of the surgeon as well as the esthetic demands of patients have become increasingly important with the development of breast conservative surgery.

MATERIALS AND METHODS

In this retrospective study, we reviewed 30 patients (mean age: 62.3 years) who were operated for a tumor of the upper outer quadrant (50 %) or the axillary tail (50 %) of the breast and who received a "V" axillary incision between 2008 and 2012. The incision draws a "V" that comprises a horizontal incision in an axilla fold associated with a vertical arcuate incision in a Langer line of the breast. The number and type of postoperative complications were collected. Patients were asked about the quality of their scar, position of the areola and breast shape was notified during consultations control.

RESULTS

The mean follow-up of patients was 32.7 months. No postoperative complications were observed. A percentage of 86.6 % of patients rated their scar result as excellent. We found no areolar malposition and no morphological deformation of the breast. The surgeons who performed this technique were very pleased with the wide exposure and the uniqueness of this incision fully respecting the architecture of the breast.

CONCLUSION

"V" axillary incision is a useful and easily reproducible technical option for the management of tumors of the upper outer quadrant and the axillary tail of the breast.

Factors affecting cosmesis after breast conserving surgery without oncoplastic techniques in an experienced comprehensive breast center

We aimed to study the factors affecting cosmetic outcome (CO) in breast conserving surgery (BCS) without oncoplastic techniques in our center with a BCS rate higher than 60% in more than 1000 breast cancer surgeries a year. In this study 284 patients who underwent BCS without oncoplastic techniques were included. Surgeries were performed by two experienced breast surgeons with more than 25 years of experience. These patients were followed in our established Wellness Clinic postoperatively. The CO is evaluated according to the "Harvard Breast Cosmesis Grading Scale" by a breast surgeon who did not participate in the patient's surgery. The correlation among patient factors (age, breast volume, menopausal status), tumor factors (size, location, distance to areola) and treatment factors (excision volume, breast skin excision, axillary surgery, adjuvant therapy) and CO were evaluated. The mean age was 57.6 [33-98] years in the successful CO group and 58.1 [34-85] years in the unsuccessful CO group (p > 0.05). The mean follow-up time was 37.9 [24-84] months. The CO was successful in 88.7% (n:252) of the patients. Tumor size, retroareolar location of the tumor, adjuvant chemotherapy administration and whole breast radiation therapy (WBRT) were correlated with a poorer CO (p < 0.05). We were able to attain a successful CO in approximately 90% of our patients. Adding oncoplastic techniques to the surgical management of larger tumors and retroareolar tumors, may increase the percentage of good CO. In selected patients choosing balloon brachytherapy instead of WBRT, may also have positive effects on CO.

Genetic polymorphisms in DNA repair and damage response genes and late normal tissue complications of radiotherapy for breast cancer

Breast-conserving surgery followed by radiotherapy is effective in reducing recurrence; however, telangiectasia and fibrosis can occur as late skin side effects. As radiotherapy acts through producing DNA damage, we investigated whether genetic variation in DNA repair and damage response confers increased susceptibility to develop late normal skin complications. Breast cancer patients who received radiotherapy after breast-conserving surgery were examined for late complications of radiotherapy after a median follow-up time of 51 months. Polymorphisms in genes involved in DNA repair (APEX1, XRCC1, XRCC2, XRCC3, XPD) and damage response (TP53, P21) were determined. Associations between telangiectasia and genotypes were assessed among 409 patients, using multivariate logistic regression. A total of 131 patients presented with telangiectasia and 28 patients with fibrosis. Patients with variant TP53 genotypes either for the Arg72Pro or the PIN3 polymorphism were at increased risk of telangiectasia. The odds ratios (OR) were 1.66 (95% confidence interval (CI): 1.02-2.72) for 72Pro carriers and 1.95 (95% CI: 1.13-3.35) for PIN3 A2 allele carriers compared with non-carriers. The TP53 haplotype containing both variant alleles was associated with almost a two-fold increase in risk (OR 1.97, 95% CI: 1.11-3.52) for telangiectasia. Variants in the TP53 gene may therefore modify the risk of late skin toxicity after radiotherapy.

Genetic predictors of long-term toxicities after radiation therapy for breast cancer

Telangiectasia and subcutaneous fibrosis are the most common late dermatologic side effects observed in response to radiation treatment. Radiotherapy acts on cancer cells largely due to the generation of reactive oxygen species (ROS). ROS also induce normal tissue toxicities. Therefore, we investigated if genetic variation in oxidative stress-related enzymes confers increased susceptibility to late skin complications. Women who received radiotherapy following lumpectomy for breast cancer were followed prospectively for late tissue side effects after initial treatment. Final analysis included 390 patients. Polymorphisms in genes involved in oxidative stress-related mechanisms (GSTA1, GSTM1, GSTT1, GSTP1, MPO, MnSOD, eNOS, CAT) were determined from blood samples by MALDI-TOF. The associations between telangiectasia and genotypes were evaluated by multivariate unconditional logistic regression models. Patients with variant GSTA1 genotypes were at significantly increased risk of telangiectasia (OR 1.86, 95% CI 1.11-3.11). Reduced odds ratios of telangiectasia were noted for women with lower-activity eNOS genotype (OR 0.58, 95% CI 0.36-0.93). Genotype effects were modified by follow-up time, with the highest risk observed after 4 years of radiotherapy for gene polymorphisms in ROS-neutralizing enzymes. Decreased risk with eNOS polymorphisms was significant only among women with less than 4 years of follow-up. All other risk estimates were nonsignificant. Late effects of radiation therapy on skin appear to be modified by variants in genes related to protection from oxidative stress. The application of genomics to outcomes following radiation therapy holds the promise of radiation dose adjustment to improve both cosmetic outcomes and quality of life for breast cancer patients.

Cosmetic outcome of breast conservative treatment for early stage breast cancer

PURPOSE

To evaluate the cosmetic outcome of breast conservative therapy and to examine the degree of agreement between the patients' and oncologists' ratings. We also analyze the influence of several factors on cosmesis.

METHODS AND MATERIALS

We retrospectively evaluated 145 patients with primary breast cancer treated by local excision and radiotherapy between January 2000 and May 2001. Cosmetic outcome was evaluated by doctors and patients and was scored as excellent, good, fair or poor.

RESULTS

73% of patients rated cosmesis as excellent or good while the percentage was 71% when rated by radiation oncologists. The degree of cosmesis concordance evaluated by oncologists and patients was low (kappa = 0.3). In our study the variables which significantly influence on the cosmetic outcome were concomitant adjuvant chemotherapy (p = 0.04) and radiation therapy boost, either by electron beam or brachytherapy (p = 0.013).

CONCLUSION

The cosmetic outcome of breast conserving therapy was good. There was a similar rating by the patient and radiation oncologist, but the level of concordance between patients and doctors was low. Factors that significantly influence the cosmesis appear to be concomitant adjuvant chemotherapy and radiation therapy boost.

Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer

Twenty-four experts from 13 different countries were asked to evaluate photographs taken of 60 women following conservative breast cancer treatment. The esthetic result of each case was classified as poor, fair, good or excellent. Agreement was evaluated using the kappa (k) and weighted kappa (wk) statistics, for all observers, male and female participants, those younger and older than 50 years, those seeing more than 250 cases a year, and those with previous publications in this area. Consensus was obtained by way of a modified Delphi approach, when more than 50% of participants provided the same classification. In a second round, consensual cases were disclosed and a revised opinion was asked in non-consensual ones. Agreement between all participants was fair (k=0.24, wk=0.37) and remained within the same range (k=0.20-0.31, wk=0.31-0.45) in the subgroups analyzed. First round consensus was obtained in 46 out of 60 cases (77%) and in the second round in 59 out of 60 cases (98%). Evaluation of the esthetic results of conservative treatment for breast cancer is only fairly reproducible when performed by experts working in different geographical areas. Consensus is obtainable if a relatively low threshold of agreement is considered acceptable.

Choosing observers for evaluation of aesthetic results in breast cancer conservative treatment

PURPOSE

The subjective evaluation of aesthetic results in conservative breast cancer treatment has largely been used without questioning the observer's skills. The aim of this study was to evaluate interobserver agreement of the aesthetic results of breast cancer conservative treatment in three groups of observers with different levels of experience.

METHODS AND MATERIALS

Photographs were taken of 55 women who had undergone conservative unilateral breast cancer treatment and 5 control women with no breast disease. The images were then distributed to 13 observers who were divided into three groups according to their experience in breast cancer treatment: experienced, medium experienced, and inexperienced. They were first asked to distinguish the patients from the controls and for the patients to identify the operated side. Subsequently, they were asked to classify the aesthetic result as excellent, good, fair, or poor. The accuracy in identifying controls, patients, and side of treatment was calculated individually for all observers. The interobserver agreement for the aesthetic result was calculated using observed agreement and multiple kappa statistic (kappa) in each of the three groups.

RESULTS

Inexperienced observers performed significantly worse than experienced observers in identifying controls, patients, and the side of treatment. Agreement of the aesthetic result was significantly greater in the group of experienced observers (kappa = 0.59) than in the medium experienced (kappa = 0.35) and inexperienced (kappa = 0.33) observers.

CONCLUSION

Previous experience in breast cancer conservative treatment should be considered a prerequisite for the evaluation of the aesthetic results.

Reduction of radiotherapy-induced late complications in early breast cancer: the role of intensity-modulated radiation therapy and partial breast irradiation

Radiotherapy after conservation surgery has been proven to decrease local relapse and death from breast cancer, and is now firmly established in the management of early breast carcinoma. Currently, the challenge is to minimise the morbidity caused by this treatment without losing its efficacy. This review will be divided into two parts, with Part I focusing on the radiation factors contributing to late normal tissue complications after radiotherapy for early breast cancer. Three major normal tissue side-effects will be discussed: cosmetic outcome, cardiac complications and pulmonary side-effects.